=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295922482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA L. LOCKWOOD PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 07/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 453 COVENTRY LN SUITE 103A
-----------------------------------------------------
City | CRYSTAL LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60014-7504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-754-1488
-----------------------------------------------------
Fax | 815-356-1488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 453 COVENTRY LN SUITE 103A
-----------------------------------------------------
City | CRYSTAL LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60014-7504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-754-1488
-----------------------------------------------------
Fax | 815-356-1488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071006634
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------